Excellent diagnostic skills protect APNs against litigation

Failing to establish a timely, accurate diagnosis can put advanced practice nurses (APNs) at risk for a lawsuit should a patient suffer harm because of your mistake. Even if you conscientiously conduct regular and thorough assessments, consider all test results, and refer patients as needed, you could still find yourself in court as a defendant if you fail to document your findings, diagnoses, and actions. In fact, the study Nurse Practitioner 2012 Liability Update: A Three-part Approach found that failure to diagnose and delay in making the correct diagnosis were the most frequent allegations in APN claims. It’s important to understand the risks of not making a correct diagnosis, skimpy documentation, or lack of follow-up and take steps to mitigate your risk of being named in a lawsuit.

A Common Claim

The Nurse Practitioner 2012 Liability Update, which examined paid insurance claims, revealed the importance of a prompt and accurate diagnosis. Consider these facts:

• Diagnosis-related claims accounted for 43% of all paid claims (30% failure to diagnose plus 13% delay in establishing a diagnosis). 
• Diagnosis-related allegations were most likely to involve failure to diagnose or delay in the diagnosis of infections, abscesses, sepsis, and cancer. In fact, these allegations accounted for more than half of the failure to diagnose claims. 
• The most common causes for diagnosis-related allegations were failure to order appropriate tests to establish a diagnosis, failure to obtain needed consultations, failure or delay in obtaining and addressing diagnostic test results, and failure to refer patients for emergency treatment. 

Clearly, making the correct diagnosis, including obtaining appropriate consults and ordering needed tests, as well as analyzing the results and making referrals as needed, are essential to patient safety. You can take the initiative to prevent yourself from becoming a statistic by following these guidelines.

Know Expectations 

You can’t meet expectations if you don’t know what they are. You should be aware of expectations from the nurse practice act in the state where you practice, facility policies and procedures, and national standards. 

Your state’s nurse practice act will provide parameters for the scope of your responsibility as an APN. This includes any requirements related to physician collaboration and supervision. Review practice agreements with physicians at least annually and ensure they provide appropriate support for the services you provide. You should also annually review federal regulations related to APNs. 

Your facility’s policies, procedures, and protocols will also guide you as you assess and diagnose patients. Policies are typically based on requirements from accrediting bodies such as The Joint Commission and from government agencies such as the Centers for Medicare & Medicaid Services, as well as state regulations. Procedures and protocols typically incorporate current evidence from the literature, so it’s important to follow them and to document completely and, if for some reason you decide not to, document why you deviated from the standard. You should also read and understand your job description. 

In a legal case, you will be held to standards from the American Nurses Association (ANA) and other national associations. Review ANA standards and ensure you comply with them. You should also review and comply with standards from APN professional, specialty, or state associations. 

According to the ANA, the APN: 

• systematically compares and contrasts clinical findings with normal and abnormal variations and developmental events in formulating a differential diagnosis.
• uses complex data and information obtained during interview, examination, and diagnostic processes in identifying diagnoses.
• assists staff in developing and maintaining competency in the diagnostic process.

In addition, APNs must adhere to standards from professional associations such as the American Association of Nurse Practitioners (AANP). AANP standards state that the APN makes a diagnosis by: 

• using critical thinking in the diagnostic process. Signs and symptoms for different medical conditions come in all forms and combinations, making it sometimes difficult to pin down a diagnosis. Is that dry, hacking cough a sign of bronchitis or lung cancer? Is the oddly colored mole benign or a sign of melanoma? Results from history taking, physical assessment, and diagnostic tests help in making a diagnosis, but you also must have excellent critical thinking skills. For more information, see Critical thinking: An essential skill. 
• synthesizing and analyzing the collected data. 
• establishing priorities to meet the health and medical needs of the individual, family, or community. 

The standards also state the APN needs to maintain accurate, legible, and confidential records. You may need to adhere to additional standards depending on where you work and the types of patients in your practice. For example, the American Association of Critical-Care Nurses (AACN) has standards for acute-care APNs. 

Ensure Your Diagnostic Skills are Current

You have a duty to obtain the information and education you need to keep your practice skills current, including your diagnostic skills. Participate in live and online continuing education programs and read professional journals to keep abreast of new developments. 

Your diagnosis may be faulty if you fail to conduct a proper assessment. Keep in mind areas that are frequently missed, such as asking patients about any herbs and supplements they take. Protocols can help ensure your assessment is correct and thorough. For example, when assessing a patient who may have been a victim of sexual assault while under the influence of drugs, collect data in accordance with protocols to help ensure you have what you need to make a correct diagnosis. 

Use of standard order sets can help ensure you don’t miss ordering a necessary diagnostic test. Remember to check the results of all tests you order. This is common sense, but it’s easy to forget when you are busy and when a patient requires multiple tests. You might want to develop a paper or online “tickler file” by date to remind yourself of tests that are due back. 

Be alert for diagnoses that are more likely to be missed such as infection and cancer. Maintain a high index of suspicion for diseases with high morbidity and mortality such as heart disease, hypertension, and diabetes. Consider the patient’s family members and significant others as sources of information; they likely know the patient better than you do, particularly if the patient is cognitively impaired. Finally, and most importantly, use evidence-based clinical practice guidelines and protocols when establishing a diagnosis.

Refer As Needed and Follow Up

Know when you need outside help, whether it’s informal consultation with your colleagues or a referral to a specialist. Indications that you need a referral include when patients with recurring signs and symptoms aren’t responding to prescribed treatments. After you make the referral, follow up to ensure the patient was seen and to review results. 

Refer patients who are unstable or have acute symptoms to emergency care. Provide an oral and written report on the patient’s condition to the clinician to ensure information is not lost during transfer and that you have documentation supporting your actions.

Establish a Partnership with Your Patients

You need to know patients’ preferred languages and their cultural backgrounds to establish an effective working relationship. You should also let patients know that you expect them to be active participants in their care. That includes sharing information with you, even if it might be embarrassing. Tell patients that you are not going to judge them in discussions on sensitive topics such as sexual behaviors or alcohol intake. The more patients feel free to speak up, the more likely they will share what you need to know to make the correct diagnosis. 

Maintaining a good working relationship with patients includes keeping them informed of test results, diagnoses, and the treatment plan. This is not only good patient care; it also can help you avoid litigation. For example, if you tell a patient when test results are expected back, he or she is likely to call you if you fail to call, thereby catching your mistake in not checking a lab result. In addition to prompt notification of diagnostic tests, schedule follow-up appointments without delay.

Document, Document, Document

The classic dictum you learned in nursing – and nurse practitioner – school, “If it wasn’t documented, it wasn’t done,” still applies. Documentation needs to be complete, timely, legible, and accurate. Whether you are using paper or electronic patient records, keep in mind that a complete health information record is the best legal defense. Examples of what you should document related to diagnosis include:

• in-person and telephone discussions with the patient or appropriate party about normal and abnormal diagnostic tests as well as recommendations for continued treatment and patient responses 
• informed consent for diagnostic tests associated with risks 
• rationale for any deviation in practice from established clinical protocols 
• dated and signed referrals and consultations, including follow-up educational materials given to the patient 
• counseling of patients who are nonadherent (e.g., when the patient refuses a recommended test). 

Documentation should follow standards established by professional nursing associations and federal and state regulations, as well as comply with your facility’s guidelines. The latter is particularly important in the case of late entries and corrections. Juries may view these as evidence of that you weren’t thorough in caring for the patient, so you need to strictly follow procedures. In addition, never alter the medical record and never include subjective opinions. If you have any questions about documentation, contact your facility’s risk manager. 

Questions to Assess Your Risk

Answer these questions to evaluate your skills related to diagnosis in terms of risk for litigation: 

• Do you use an objective, evidence-based approach, applying approved clinical guidelines and standards of care, to timely and accurately determine the patient’s differential diagnosis? 
• Do you consider the findings of the patient’s assessment, history, and physical examination, as well as the patient’s expressed concerns, in establishing the diagnosis and document your findings? 
• Do you order and timely obtain results of appropriate diagnostic testing before determining the diagnosis, and document ordered tests and results? 
• Do you consult with your collaborating/supervising physician, as required, to establish the diagnosis and treatment plan, and document these encounters? 
• Do you request, facilitate, and obtain other appropriate consultations as necessary? 
• When establishing the diagnosis, do you comply with the standard of care, as well as your facility’s policies, procedures, and clinical and documentation protocols? 
• Do you refer unstable patients to hospital emergency care and facilitate the process as necessary? 
• Do you conduct and document informed consent discussions with patients who require a diagnostic test or procedure that involves risk, and obtain a witnessed consent? 
• Do you proactively gather, document, and respond to results of diagnostic tests and procedures and provide necessary orders? 
• Do you obtain, document, and respond to the results of diagnostic consultations with physicians and other healthcare providers? 
• Do you discuss clinical findings, diagnostic test/ procedure results, consultant findings, diagno¬sis, the proposed treatment plan, and reason¬able expectations for a desired outcome with patients and document the process, including the patient’s response? 
• Do you counsel the patient about the risks of not complying with diagnostic testing, treatment and consultation recommendations, and document the discussions? If recurrent nonadherence is affecting the safety of the patient and counseling has been ineffective, do you consider discharging the patient from the practice? 
• Do you refer patients who are uninsured or unable to afford needed diagnostic tests, procedures, and consultations for financial assistance, payment counseling, and/or free or low-cost alternatives? Do you document you have done so? 
• If you work in a state with autonomous nurse practitioner authority, do you regularly seek peer review to assess your diagnostic skills and expertise and to identify opportunities for improvement?

Assessment of your diagnostic skills and processes is just one component of what you should consider when analyzing your potential risk for litigation. Other self-assessment categories include clinical specialty, scope of practice and scope of services, assessment, treatment and care, medi¬cation prescribing, competencies, patient care equipment and supplies, professional conduct, and general documentation practices. Consult this easy-to-use checklist for addressing each of these areas.

Critical Thinking: An Essential Skill

To be a good critical thinker, you need to be creative, inquisitive, flexible, open-minded, and diligent in seeking relevant information. You also must be aware of the danger of making decisions based on emotion rather than reasoning. Here are some other tips for thinking critically when making a diagnosis.

• Be aware of possible bias when analyzing data; we tend to give more weight to facts that support our views and less to those that don’t. 
• Set aside any preconceived ideas you have about what the diagnosis will be and start with an open mind. 
• Don’t make assumptions about the person or the data you have collected. 
• Put the data in context. For example, an emotional divorce in a patient’s life may affect how he or she responds to some history-taking questions. 
• Identify all the possible options and determine what sup¬ports and doesn’t support each. 
• Test your diagnosis by ordering the appropriate treatment and then evaluating its effect.

Helping You and Your Patients

Remember that taking the steps you need to make an accurate diagnosis not only protects you from litigation, it also protects your patients from harm.

RESOURCES 

• Alfaro-Lefevre R. Critical Thinking, Clinical Reasoning, and Clinical Judgment: A Practical Approach, 5th ed. Saunders; 2011. 
• American Association of Critical Care Nurses. AACN Scope and Standards for Acute Care Nurse Practitioner Practice. 2012. http://www.aacn.org/wd/ practice/docs/acnp-scope-and-standards.pdf. 
• American Association of Nurse Practitioners. Standards of Practice for Nurse Practitioners. http://www.aanp.org/images/documents/publications/ standardsofpractice.pdf. 
• American Nurses Association. Nursing: Scope and Standards of Practice. 2nd ed. 2010. Silver Spring, Md.: American Nurses Association. 
• CNA, NSO.Nurse Practitioner 2012 Liability Update: A Three-part Approach. http://www.nso.com/nursing-resources/claim-studies. jsp?refID=npclaimreport2012. 
• Author: Cynthia Saver, MS, RN, President, CLS Development, Columbia, Maryland.

This risk management information was provided by Nurses Service Organization (NSO), www.nso.com, 1-800-247-1500.

CANP endorses the individual professional liability insurance policy administered through NSO and underwritten by 
American Casualty Company of Reading, Pennsylvania, a CNA company. Reproduction without permission of the publisher is prohibited. For questions, send an email to service@nso.com.